Retention and Clinical Transfer of Surgical Skills Across Virtual, Physical, and Hybrid Simulation Modalities: A Scoping Review
This scoping review of 48 empirical reports concludes that surgical skill retention and transfer to the operating room depend more on curriculum design factors like deliberate practice and task alignment than on simulation modality alone, advocating for the strategic selection of virtual, physical, or hybrid training based on specific learning objectives rather than treating any single modality as a universal solution.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Surgery is a craft where the hands must learn to move with precision before they ever touch a patient. For centuries, the only way to learn this was to practice on the living, a process that carried an inherent risk for the person on the table. To solve this, medical schools turned to simulation, creating safe environments where trainees could make mistakes without consequence. These practice spaces come in different forms. Some are physical, using boxes with rubber tissues, synthetic models, or even preserved human bodies to mimic the feel of real anatomy. Others are virtual, using screens and controllers to create digital worlds where the surgeon can see and manipulate a patient without a physical presence. There are also hybrid approaches that mix the two. The central question for educators has long been whether the skills learned in these practice rooms actually stick over time and whether they work when the trainee finally steps into a real operating room.
A new review of research, conducted by scholars at the Popular University of Cesar and the Corporación Universitaria Rafael Núñez, set out to map exactly how well these skills survive the journey from the lab to the hospital. The researchers gathered and analyzed forty-eight different studies that tracked surgeons after they finished their training. They looked for evidence of two specific things: retention, which is the ability to remember a skill after a period of not using it, and transfer, which is the ability to use that skill in a different setting, such as moving from a simulator to a live patient. The team sorted the studies based on what they measured, ranging from simple checks of whether a skill was remembered on the same machine, to the most difficult test: whether the training actually improved outcomes for the patient.
The review found that the type of practice room matters less than how the training is structured. While physical laboratories were the most common setting in the studies, appearing in nearly half of the reports, and virtual labs were used in about a third, neither technology proved to be a universal winner on its own. The studies showed that skills could be transferred to the operating room, particularly in fields like laparoscopic surgery, where small incisions are made and tools are used through a camera. However, this success was not automatic. It happened most consistently when the training was built around a clear goal of mastery rather than just attendance. If a trainee practiced until they reached a specific standard of performance, received clear feedback on their errors, and repeated the task deliberately, the skills were much more likely to last and to work in the real world.
The researchers also discovered that time is a critical factor in how well a surgeon remembers what they have learned. About twenty of the studies looked at how long skills lasted after training stopped. The evidence suggests that without regular practice, performance begins to fade, especially for complex tasks like tying knots or handling delicate tissue. The most common time frame for checking if a skill was still intact was between three and six months. The data indicates that a single burst of practice is not enough to build a permanent foundation. Instead, skills need to be maintained through spaced practice, where a trainee returns to the task periodically to keep their proficiency sharp. The review noted that while many studies proved that surgeons could perform better in the operating room after training, very few actually measured whether this led to fewer complications or better health for the patients. Only one study in the entire group reached that highest level of proof.
This gap in the evidence highlights a crucial distinction: doing a procedure faster or more smoothly in the operating room does not automatically mean the patient is safer. The review argues that the value of a simulation lab should not be judged by how high-tech it is, but by how well it is designed to prepare a surgeon for the specific challenges they will face. The authors propose a new framework for designing these courses, one that asks whether the practice matches the real task, whether the training includes enough repetition to prevent forgetting, and whether the assessment is fair and valid. They emphasize that the goal is not to replace the operating room with a machine, but to create a pathway where the skills learned in the lab are durable, ethical, and ready for the moment they are needed most. The ultimate measure of success remains the safety and well-being of the patient, a standard that requires more than just a good score on a simulator.
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